Back to referral guidelines
Print Friendly, PDF & Email
Primary care management and referral guideline Primary care management and referral guideline

Eczema in Children – Management and referral guideline

Red flags

  • Febrile or unwell child
  • Erythrodermic child – all skin red and/or inflamed
  • Disseminated eczema herpeticum and/or ocular involvement
  • Severely infected eczema
  • Extensive eczema and parental exhaustion

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

  • Eczema is a chronic skin condition marked by chronic redness, dryness and itch, underpinned by a defective barrier function of the skin.
  • Eczema is very common, affecting up to 30% of Australian children. It is highly heritable, with other family members often suffering from eczema or other atopic disorders (hay fever, asthma).
  • Eczema is thought to be caused by a complex interplay between genetic defects in skin barrier function, upregulation of inflammatory cytokines and environmental factors e.g., second hand smoke, climate, soaps.
  • In infants it can be seen in newborns, and will usually appear as redness to the face, neck, and trunk.
  • In preschool‑aged and older children, eczema tends to present as erythema and dryness to the skinfolds of the arms and legs.
  • 80% of children will grow out of eczema by the age of 16.
  • Eczema cannot be cured, but can be effectively managed.

Assessment

Take a history. Ask about:

  • past history of eczema.

    Past history of eczema

    • Age of onset.
    • Past treatments.
    • Infections.
  • atopic disease – asthma, rhinitis.
  • gastrointestinal symptoms.
  • food allergies.
  • effect of eczema on child and family.

    Effect of eczema on child and family

    • Scratching.
    • Sleep quality.
    • Daytime function.
    • Cost of treatment.
  • current eczema management.

    Current eczema management

    • Parental understanding of eczema.
    • Awareness and avoidance of triggers e.g., heat, prickly fabrics, soaps.
    • Frequency of bathing and use of additives.
    • Frequency, location, and type of topical treatment applied and any stinging experienced.
    • Use of wet dressings and bleach baths.
    • Any diet restriction in child or breast feeding mother.
    • Alternative practitioner consultation.
    • Previous use of and comfort with topical steroid use.

Examine skin to assess

  • severity of eczema.

    Severity of eczema
    Assess severity, including distribution, chronicity, impact on quality of life using the NICE guidelines.

  • presence of infection.

    Infection in eczema
    Infection is suggested by a flare of eczema particularly with crusts, weeping, erythema, and increased itch.

    Bacterial:

    • Usually staphylococcus.
    • Presents with weeping yellow scabs, pustules, and erythema.

    Viral:

    • Herpes simplex virus (HSV) can lead to eczema herpeticum.
      • Characterised by grouped vesicles, satellite lesions, pustules and erosions.
      • Often tender rather than itchy.
      • Eczema herpeticum is a dermatological emergency.
    • Molluscum contagiosum can be extensive in children with eczema.

Consider differential diagnosis.

Differential diagnosis

  • Infantile seborrhoeic dermatitis – not itchy, predominantly located around the neck, scalp, and nappy region.
  • Scabies:
    • Consider in non-atopic child with sudden onset.
    • Presents as itchiness, with erythematous papular eruption, particularly if typical burrows between finger webs, axillae, umbilicus, and genital regions.
    • Assess if other family members are itchy and have a skin eruption as well.
  • Periorificial dermatitis – consider where irritation, pustules around mouth, nose, and eyes. This will be exacerbated by moderate or potent steroids.
  • Psoriasis – itchy, well defined silvery scaly plaques on elbows, knees, and scalp.
  • Miliaria.
  • Nutritional deficiency e.g., zinc, iron, metabolic disorders.
  • Histiocytosis.
  • Immunodeficiency – consider in an infant with significant eczema as well as poor growth, persistent diarrhoea, or repeated infection.

Consider arranging iron studies. Iron deficiency can contribute to poor healing of the skin and can be associated with chronic eczema.

Management

Discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate if:

  • febrile or unwell child.
  • erythrodermic child – all skin red / inflamed.
  • disseminated eczema herpeticum / ocular involvement.
  • severely infected eczema.
  • extensive eczema and parental exhaustion.

Provide education about eczema.

Education about eczema

  • Explain pathophysiology of eczema:
    • dryness – requiring daily tepid bath, and moisturiser which hydrates, provides a barrier, and prevents evaporation.
    • inflammation – requiring topical steroid treatment when inflamed.
  • Advise skin irritation leads to a cycle of scratching, itching, and poor sleep.
    Discuss avoidance of triggers.

    Avoiding triggers

    • Heat – avoid overdressing and overheating as heat is a significant trigger.
    • Irritating clothing e.g, woollens – wear cotton clothing.
    • Chemicals in soaps – use QV or similar products for bathing.
    • Chemicals in laundry detergents – use sensitive fragrance-free laundry products.
  • Indicate there is no cure, but eczema can be effectively managed and will improve with time:
    • 50% significantly improved by age 2 years.
    • 80% by age 5 years.
  • Discuss allergy:
    • There is no one allergen that causes eczema.
    • Aero allergens such as dust mite, animal dander, and pollens maybe contributory, but removal does not significantly improve eczema.
    • Food allergies may be a factor in those with moderate to severe eczema:
      • Usually in young infants with quite severe eczema.
      • Often with additional symptoms such as acute gastrointestinal symptoms or acute urticaria following ingestion of specific food.

Start everyday skin treatment:

  • Avoid triggers.

    Avoiding triggers

    • Heat – avoid overdressing and overheating as heat is a significant trigger.
    • Irritating clothing e.g, woollens – wear cotton clothing.
    • Chemicals in soaps – use QV or similar products for bathing.
    • Chemicals in laundry detergents – use sensitive fragrance-free laundry products.
  • Apply moisturiser and/or emollient at least twice daily.

    Moisturisers and emollients

    • Ointments are preferred over creams. Lotions are not effective for eczema.
    • Avoid “natural” animal or plant‑based moisturisers as these can be more irritating to the skin.
    • Use large pump pack or, if the emollient is in a container, use a spatula to avoid contamination.
    • Apply liberally all over the body, up to 6 times per day.
    • Apply over topical steroids.
  • Bathe daily, avoiding soap.

    Bathe daily

    • Use tepid water with bath oil or soap substitute that doesn’t lather e.g., aqueous cream, soap‑free wash.
    • Avoid bubble bath.
    • Pat skin dry and apply moisturiser promptly.
  • If infection suspected to be causative, consider twice weekly antibacterial bath.

    Antibacterial bath

    • Bleach.
    • Salt and bath oil.
    • Permanganate – only use enough to turn water light pink. If too concentrated, it may stain hard surfaces.

    Provide Eczema – Bathing Your Child fact sheet for detailed information.

If skin is red, dry, and itchy, start flaring skin regime:

  • Continue everyday skin treatment as above.
  • Apply topical steroids daily to red, rough, and itchy areas of skin after bath and before moisturiser.
    Topical steroids
    Ointments are superior to creams, and lotion can be used on the scalp.

    • Prescribe mild to moderate potency steroid for the face and moderate to potent steroid for the body. Discuss topical steroids with parents to reassure regarding safety:
      • The side‑effect potential for topical steroids has been overstated in the past, leading to poor adherence to treatment.
      • Using steroids early and liberally lessens total dose of steroid over time and is preferable.
      • Daily use of topical steroids on eczematous skin in 1 location for 4 weeks does not carry a risk of thinning of the skin. Using for this length of time without improvement represents a failure of treatment and should lead to further assessment and a change in management plan.
  • Return to everyday skin treatment when skin improves and eczema has settled.
  • Consider topical immunomodulators (e.g Elidel) to increase time between flares of mild eczema, particularly to the face peri-orbital area.
    Consider topical immunomodulators
    Ointments are superior to creams, and lotion can be used on the scalp.

    • Used as maintenance therapy between flares.
    • Has no role for use on the body or in the treatment of acutely flared eczema.
    • Used in place of topical steroids once eczema has settled.

If not improving after 48 hours with adequate use of topical steroids:

  • Continue emollient and topical steroids as above.
  • Start antibacterial measures.

    Antibacterial measures

    • Start antibacterial baths, or increase frequency to daily. See Children’s Health Queensland – Eczema: Bathing Your Child.
    • If clinically suspicious for bacterial skin infection:
      • Swab lesion.
      • Start oral antibiotics:
        1. Di/flucloxacillin 12.5 mg/kg (up to 500 mg) every 6 hours for 5 to 10 days, or
        2. Cephalexin 12.5 mg/kg (up to 500 mg) orally, every 6 hours for 5 to 10 days.
      • Avoid topical antibiotics as these are ineffective and contribute to resistance.
  • Consider herpes simplex virus.

If not improving after 2 weeks with adequate use of topical steroids and anti-infective measures:

  • Continue emollient, steroid, and anti-infective measures as above.
  • Add wet wraps or garments to intensify treatment. See Children’s Health Queensland – Eczema: How to Use Wet Wraps.
  • Ensure optimisation of general health, particularly correcting any iron deficiency.
  • If considering oral corticosteroids, be aware that they are generally not indicated in the treatment of eczema.
    • Often result in a rebound flare and exacerbation of infective eczema
    • May be effective in reducing eczema in an acute setting

If not improving after all above measures, discuss with your local paediatric dermatology team and refer for acute assessment.

If improving but dermatology review required for optimisation of treatment, refer to your local paediatric dermatology service.

If suspected allergic disease, refer to your local paediatric immunology and allergy service.

If suspected systemic disease (e.g., immunodefiency), discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate.

When to refer

  • Discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate if:
    • febrile or unwell child.
    • erythrodermic child – all skin red / inflamed.
    • disseminated eczema herpeticum / ocular involvement.
    • severely infected eczema.
    • extensive eczema and parental exhaustion.
  • If eczema not improved with adequate topical steroids and anti-infective measures, discuss with your local paediatric dermatology team and refer for acute assessment.
  • If suspected systemic disease (e.g., immunodeficiency), discuss with your local paediatric team on call or arrange transfer to your nearest ED as appropriate.
  • If eczema improving but dermatology review required for optimisation of treatment, refer to your local paediatric dermatology service.
  • If suspected allergic disease, refer to your local paediatric immunology and allergy service.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging
    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

Insert the required information into referral.

  • Patient’s demographic details.
    • Full name, including aliases.
    • Date of birth.
    • Residential and postal address.
    • Telephone contact number(s) – home, mobile and alternative.
    • Medicare number, where eligible.
    • Name of the parent or caregiver, if appropriate.
    • Preferred language and interpreter requirements.
    • Identifies as Aboriginal and/or Torres Strait Islander.
  • Practitioner details
    • Full name.
    • Full address.
    • Contact details – telephone, fax, email.
    • Provider number.
    • Date of request.
    • Signature.
  • Relevant clinical information about the condition
    • Presenting symptoms – evolution and duration.
    • Physical findings.
    • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment.
    • Body mass index (BMI).
    • Details of any associated medical conditions which may affect the condition or its treatment (e.g., diabetes), noting these must be stable and controlled before the request.
    • Current medications and dosages.
    • Drug allergies.
    • Alcohol, tobacco, and other drugs use.
  • Clinical modifiers
    • Impact on education.
    • Impact on home.
    • Impact on activities of daily living (ADLs).
    • Impact on ability to care for others.
    • Impact on personal frailty or safety.
    • Identifies as Aboriginal and/or Torres Strait Islander.
  • Other relevant information
    • Willingness to have surgery, where surgery is a likely intervention.
    • Choice to be treated as a public or private patient.
    • Compensable status e.g., DVA card, WorkCover policy number, motor vehicle insurance.
  • Reason for request
    • To establish a diagnosis.
    • For treatment or intervention.
    • For advice and management.
    • For specialist to take over management.
    • Reassurance for general practitioner or second opinion.
    • For a specified test or investigation unavailable to the general practitioner, or the patient can’t afford or access.
    • Reassurance for the patient and family.
    • For other reason e.g., rapidly accelerating disease progression.
    • Clinical judgement indicates a referral for specialist review is necessary.

Relevant pathology and radiology results (printed for the patient and sent with the referral).

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 12/07/2019 Review date 1/07/2022

Disclaimer

The information contained in this GP referral and management guideline is intended for information purposes only. The information has been prepared using a multidisciplinary approach with reference to the best information and evidence available at the time of preparation. No assurance is given that the information is entirely complete, current, or accurate in every respect.
This guideline is not a substitute for clinical judgement, knowledge and expertise, or medical advice. Variation from this guideline, taking into account individual circumstances may be appropriate.
This guideline does not address all elements of standard practice and accepts that individual clinicians are responsible for the following:
  • ●  Providing care within the context of locally available resources, expertise, and scope of practice.
  • ●  Supporting consumer rights and informed decision making in partnership with healthcare practitioners including the right to decline intervention or ongoing management.
  • ●  Advising consumers of their choices in an environment that is culturally appropriate and which enables comfortable and confidential discussion. This includes the use of interpreter services where necessary.
  • ●  Ensuring informed consent is obtained prior to delivering care.
  • ●  Meeting all legislative requirements and professional standards.
  • ●  Applying standard precautions, and additional precautions as necessary, when delivering care.
  • ●  Documenting all care in accordance with mandatory and local requirements.
Children’s Health Queensland disclaims, to the maximum extent permitted by law, all responsibility and all liability (including without limitation, liability in negligence) for all expenses, losses, damages and costs incurred for any reason associated with the use of this guideline, including the materials within or referred to throughout this document being in any way inaccurate, out of context, incomplete or unavailable.

Resources

For health professionals

For families

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

feedback
Fact sheet footer